HIV and Aging

1

HIV Disease in Older Patients
Donna M. Gallagher, ANP
DM Gallagher, ANP.Presented at IASUSA/RWCA
Clinical Conference, June 2005.
The International AIDS SocietyUSA
2
Current Challenges

• Case finding in the over 50 population
• Primary Care for over 50 in HIV setting
• HIV care in the Geriatric setting
• Prevention for Positives over 50
• Medication Fatigue
• Risk Reduction Fatigue
• Compassion Fatigue

3
CDC US population Top 5 causes of death 2002

• 55-64
• Malignancy 36.9
• Cardiac disease 25.4
• Lung disease 4.5
• Diabetes 4.0
• Cerebrovascular disease 3.9

• gt 65
• Cardiac disease 31.8
• Malignancy 21.6
• Cerebrovascular disease 7.9
• Lung disease 6.0
• Alzheimer's tied with pneumonia/influenza 3.2

4
Massachusetts DPH 2004-2005People Living with HIV

• Male 72
• MSM 46, IVDU 28
• White 53, Black 22, Hispanic 23
• White MSM 66
• Black IVDU 31
• MSM 23
• Hispanic IVDU 51

• Female 28
• IVDU 34, heterosexual contact 33
• White 32, Black 39, Hispanic 28
• White IVDU 52
• Black hetero 41
• Hispanic hetero 44

5
Massachusetts DPH 2004-2005People Living with HIV

• 21 over 50 years old
• 20 45-49 years old
• 24 40-45 years old

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Massachusetts DPH 2004-2005People Living with HIV

• AIDS diagnosis within 2 months
• of HIV diagnosis ? 30
• If over 50? 42
• Higher incidence of AIDS at time of
  
• diagnosis among infections from
  heterosexual transmission
• Issues of Denial Patient and Provider

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HIV Over Fifty (Who are they?)

• 1. PLWHIV who were in their 30s when they
  became infected
• 2. Women who have begun to have sex again after a
  divorce, death or the introduction of sildenafil
  to their relationship
• 3. IVDU who have continued to have risk while
  needle sharing
• 4. Patients in mental health care, long term
  care facilities

8
Who are they (continued)?

• Patients who access the health care system and
  are not assessed for risk
• Men and women who are NOT accessing the health
  care system and are being missed
• People who see HIV prevention messages that dont
  reach them because they are not represented in
  the message

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Aging and Immune Function

• Increased co-morbidities
• Increased risk of reactivation diseases with
  aging TB, herpes zoster
• Cell mediated response to vaccines and infections
  are lost over time. Anergy testing not
  recommended
• Decreased survival after diagnosis of AIDS in
  individuals gt 50 compared to lt 40
• Increased likelihood of having AIDS at time of
  initial diagnosis

10
Aging and Immune Function

• Thymic function decreases with age is important
  in the quantitative CD4 response to HAART
• CD4 cells decrease and CD8 cells increase with
  aging so ratio needs a different view
• Genetic aging (polymorphisms in chemokine
  receptors) enhance HIV 1 progression

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Considerations

• Sexual and domestic violence as a backdrop
• Isolation
• Fear of rejection
• Meds, home remedies, herbal supplements
• Nutrition affected by poverty, lack of access,
  side effects
• Safety issues
• Responsible for caring for a loved one

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Fenway Demographics

• HIV infected patients over 50 years old
• 2000 12
• (107/917)
• 2004 19
• (202/1083)

• HIV infected patients over 60 years old
• 2000 2
• (15/917)
• 2004 3
• (34/1083)

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Fenway DemographicsCo-morbidities

• Cardiovascular disease under 50 years old
• 2000 18 (161/872)
• 2004 31 (272/881)

• Cardiovascular disease over 50 years old
• 2000 49 (44/89)
• 2004 63 (128/202)

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Fenway DemographicsCo-morbidities

• Bone disorders
• under 50 years old
• 2000 0.9 (4/795)
• 2004 1.7 (15/881)

• Bone disorders
• over 50 years old
• 2000 0.9 (1/107)
• 2004 5.4 (11/202)

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Fenway DemographicsCo-morbidities

• Neuro-cognitive disorders under 50 years old
• 2000 0.5 (4/795)
• 2004 1.0 (9/881)

• Neuro-cognitive disorders over 50 years old
• 2000 1.9 (2/107)
• 2004 0.5 (1/202)

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Bone Abnormalities

• Nutrition for Healthy Living Cohort
• Baseline Median age 42 years old
• Median CD4 count 372
  Median Viral Load 2.7 log
• DXA scan 0.22 decrease in BMD
• at one year
• 0.68 decrease in BMD at
  three years

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Bone Abnormalities

• BMD Decrease associated with
• Longer duration of didanosine and tenofovir
  treatment
• Years known to be HIV positive
• Bilirubin gt 2.0
• Less bone mass loss seen with stavudine and
  indinavir

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Neuro-Cognitive Disorders

• 67 individuals with HIV over 50 year old compared
  with 52 individuals with HIV under 35 years old
• No significant differences in demographics, CD4
  count or with AIDS, younger group with higher
  plasma and CSF viral load
• Proportion with neuro-cognitive impairment
  slightly higher in older group
• Higher rates of impairment across most ability
  domains in older group
• Older individuals with detectable CSF virus had
  twice the prevalence of neuro-cognitive deficit

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Neuro-Cognitive Disorders

• Hawaii Cohort
• 20 of people with HIV are over 50
• HIV dementia more common
• 25.2 in individuals over 50 vs. 13.7 in
  individuals 20-39 years old
• Adjusting for variables such as education, race,
  treatment and substance dependence odds of HIV
  Associated Dementia was 3.2 times more likely in
  older vs. younger group

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Conclusions

• Individuals with HIV are living longer
• HIV Risk screening and prevention counseling
  remains important in older individuals
• Co-morbidities of aging overlap with many
  co-morbidities of HIV
• HIV treatments are associated with increased risk
  of some co-morbidities
• Preventive screening for lipid abnormalities,
  osteopenia, cognitive impairments are an
  important component of comprehensive HIV care

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Challenges for the future

• Prevention messages targeted to older people
• Sex and Drug histories across the lifespan
• More information on drug-drug interactions and
  the long term impact of HIV on aging
• A plan for integrating HIV care into elder
  services